The present study aims to further explore the links between EDs and sexual violence, via the characterization of the consequences of an assault on the physical and mental health of victims with an ED and those without. It was based on the presence of an association between sexual abuse and a lifetime diagnosis of EDs in a systematic review and meta-analysis (OR: 2.72; 95% CI, 2.04–3.63) , and is the only study conducted in a large population of sexual victims.
ED prevalence was found to be 4.3% of the studied sample. This prevalence being extracted from declarative data, this number is probably underestimated. For the same reason, the data obtained do not allow an exact classification of EDs in accordance with the DSM5 , which could contribute to the absence of any significant differences between the different ED subgroups for some of the variables studied.
Our data show an increase of sphincter troubles related to sexual assault, a reported consequence of sexual abuse with frequent somatoform symptoms especially when PTSD is present . They can appear as common clinical symptoms (secondary enuresis, overactive bladder, dysuria, urinary retention…) or sometimes as neurogenic bladder .
Among the four types of EDs, RA was more frequently declared (41%). This is concordant with a previous study performed on hospitalized EDs patients in which a PTSD was found to be present in 33.9% . Thus, we answer here to an ongoing debate: a traumatic life history may be observed in RA and is not specific to patients with purging behaviors as previously reported respectively in female teenagers and adults with anorexia nervosa [33, 52], and in a meta-analysis assessing the association of distinct types of child abuse and different eating disorders, where only BN and BED were significantly associated to sexual abuse .
These discrepancies for relationship between traumatic event and ED types, could be explained by the differences in the type of traumatic events and/or their exposure duration. In the multicentric study of Reyes-Rodriguez et al. on PTSD in anorexia nervosa, the prevalence of PTSD in ED victims of sexual assaults was higher than that of victims of other traumatic events . In that study, as in the present one, PTSD prevalence did not differ between RA and AB subgroups. Otherwise, Vidana et al.  reported more purging behaviors in victims with traumatic events occurring in both childhood and adulthood than at each period of age. Another explanation to the above discrepancies might be a greater ability to repress trauma in RA subjects whose cognitive strategy induces emotion avoidance and a deficit in the perception of self and one’s own feelings [54, 55]. Alterations in autobiographical memory especially for negative events have also been reported in AN [56, 57].
As previously hypothesized by Karr et al.  to explain the presence of ED after a sexual abuse: some victims of sexual trauma adopt active food restriction to be thinner to minimize secondary sex characteristics and appear less attractive to potential perpetrators; others use bingeing or purging as a means of dissociation to “escape from” PTSD symptoms.
EDs induced by a traumatic event should thus be considered as a means to counteract emotional dysregulation, or an attempt to alleviate symptoms of PTSD, regardless of the origin of the trauma [26, 59]. When internal schemas for safety are disrupted, food may indeed serve as a transitional object, since food encompasses a symbolic significance while providing emotional comfort. Fasting and binge eating can then be used to create mood alteration that can compensate for the devastating effect of the trauma. In accordance with the narratives reported by the victims of our study, RA could be used as a way of re-taking control and feeling a power that has been taken from the victim, while binging is a response of the urge to fill up in order to forget, a filling that can be put back (BN) to ward off the pain . Interventions focused on improving emotional functioning seem to be especially beneficial for ED patients with trauma histories [61–63].
EDs co-occur frequently with PTSD, especially in BN . High levels of PTSD have been reported in subjects with EDs, and EDs are more present in subjects with PTSD [35, 65]. Moreover, as several studies reported more severe EDs whatever their type in the presence of PTSD [66–68], our data tend to confirm those of Holzer et al  and of Dubosc et al , suggesting that severe traumatic events and PTSD, especially in childhood, are in fact a causal factor of ED occurrence.
A significant association between sexual abuse and a lifetime diagnosis of anxiety disorder, depression, PTSD and suicide attempts, has been established for several decades in the scientific litterature [23, 25, 71], and seems to persist regardless of the victim’s gender or age at which abuse occurred . Suicide attempts were present in 19.3% of ED subjects in the present study, whereas they were previously reported to occur in approximately 3–20% of patients with anorexia nervosa and in 25–35% of patients with bulimia nervosa, and a significant clinical correlate of suicidality was a history of childhood physical and/or sexual abuse . Contrary to some other studies showing a positive association between purging and suicidality [73, 74], the rates of suicide attempts in our study do not significantly differ between the RA and AB subgroups. We therefore recommend a systematic assessment of suicidal ideation, regardless of the type of ED, especially when a PTSD is present. However, considering the high prevalence of depression in ED subjects victim of sexual violence (45% in our study), this assessment should be performed even in the absence of PTSD.
Apart being a causal factor of suicide attempts, childhood sexual abuse is a well-established risk factor for non-suicidal self-injury (NSSI) and was reported to be significantly associated to ED . The observed lifetime prevalence of NSSI is 20.9% in women and is not associated with an ED type and EDs associated to NSSI are more severe and general psychopathological symptoms are more frequent . In our sample, the association between NSSI and ED was quite strong with an OR of 11.50 [8.29–15.95], and it did not differ between the ED subgroups, thus confirming the previous data on the matter. Emotion dysregulation has been proposed as a causal factor of NSSI , and is a well-known consequence of trauma, as traumatic event impact cortisol and norepinephrine response, medial prefrontal cortex and amygdala functioning and the hypothalamic-pituitary-adrenal (HPA) axis which are crucial areas in emotional processing and regulation (as well as other part of the former limbic system) . It is well known that these PTSD induced neurological modifications are even more long lasting when the trauma occurs in infancy or childhood .
A higher prevalence of alcoholism in the ED subjects is also concordant with previous data showing that ED and substance use disorders commonly co-occur . Alcohol and substance use has been very well described in the literature of PTSD patients and sexual assault survivors as a coping mechanism or self-medication after a trauma, and even more so if it happened in childhood [80–84]. In a population-based sample of 1,411 female adult twins, self-reported childhood sexual abuse was positively associated with a number of psychiatric disorders, but the strongest associations were with alcohol and drug dependence, as well as bulimia . In this framework, it has been hypothesized that drugs are used to prolongate the dissociative effect of the trauma, counteract emotional dysregulation, numb recurrent traumatic recollections of the event, and/or allow fall asleep fast and avoid associated nightmares [86, 87].
An emerging concept integrates EDs into the field of addictions [88–90], these behaviours representing maladaptive coping strategies, which may offer a distraction from aversive emotional arousal . This could thus explain the recent discovery of a shared genetic risk between eating disorder- and substance-use-related phenotypes . Recent findings in animal literature outline similar neurological signatures between overeating/ BED and substance addiction .
No differences were found between ED subtypes, whereas a discrepancy between ED subtypes is reported in human litterature, with BED being more associated with alcoholism and substance abuse than RA . This could be explained by the fact that our data were extracted from declarative data that did not specifically screen for either ED or substance abuse, or could be impacted by the stigma associated with both EDs and substance addictions. Another explanation could be that the occurrence of sexual assault is not taken into consideration in many studies on EDs, which could be a confounding factor in this case. Nonetheless, a co-occurrence of ED and substance abuse should alert the professional to the existence of possible past or still ongoing sexual violence in the patient.